THIS FORM IS NOT A LICENCE
Please send completed application to
MULTI-CHOICESELF-MANAGEMENT PROGRAMME LICENCE APPLICATION
Legal name of organisation......
Address......
Name of person authorised to sign licence......
Purchase authorised by (name)...... Date......
Details of person licence to be sent to (if different from above):
Name...... Email......
Address...... Phone......
Multi Licence Levels (please tick box to indicate level required): / Level 1 / 65 community courses (combined) and 4 tutor training events / £682
/ Level 2 / 100 community courses (combined) and 6 tutor training events / £955
/ Level 3 / 150 community courses (combined) and 10 tutor training events / £1,455
/ Level 4 / 150+ community courses will be charged at £12 per course.
Please indicate the number of courses to be delivered across all programmes and the number of tutor trainings required:
Number of courses required over 3 years = [please insert details]
Number of tutor trainings required over 3 years = [please insert details]
Please note there will be a charge per tutor trained of £12 due with annual return
Please specify which programmes you would like a licence for from the following:
Programme / *Chronic Disease Self-Management Programme (CDSMP)
/ Chronic Pain Self-Management Programme (CPSMP)
/ Cancer: Thriving & Surviving (CTS)
/ Diabetes Self-Management Programme (DSMP)
/ Positive Self-Management Programme (PSMP)
/ Other
*UK Organisations that hold a licence for the CDSMP are also entitled to deliver the CDSMC for Carers (2012). All Stanford programmesrequire the necessary cross training please contact for further information
Trainers have been trained in selected programmes
Trainers will be trained in selected programmes as follows:
Training location...... Training dates......
Please send completed application to upon receipt you will be issued with an invoice and selected training licence.
A Registered Company Limited by Guarantee – Company number: 07960203
Registered office: 424 Margate Road, Westwood, Ramsgate, Kent CT12 6SJ